Pain management strategies for children presenting to the emergency department (ED) were discussed in a review published in the Journal of the American College of Emergency Physicians Open.

The pain of pediatric patients who present to the ED is often underestimated and inadequately managed. In light of the recent opioid crisis, emergency physicians are encouraged to review and adopt alternative pain management strategies.

Review authors noted that distress in children may be reduced with classic interventions such as pacifier use, swaddling, or rocking. In addition, a dedicated child area in the ED, which is equipped with activities and child-friendly wall displays, may minimize fear of foreign settings and lead to less perceived pain for some patients.


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Pain should be assessed early on arrival to the ED, and symptoms should be re-evaluated throughout the encounter. Combinatorial approaches that assess physical, psychologic, and pharmacologic strategies have been found more effective than single-approach strategies. The stop-light pain scale is a validated tool that can be used among patients aged 3 years and older.

Nonpharmacologic approaches to pain management can be grouped into 3 main categories, including behavioral, cognitive, and complementary strategies. Examples of these approaches include behavioral distraction, positive reinforcement, breathing exercises, hypnosis, virtual reality devices, and therapeutic play.

In addition, cold or vibration devices have been found to reduce pain and block further transmission of pain transmission, respectively. Some devices, such as the Buzzy device, delivers both vibration and cold via a bee-shaped device and has been found to be an effective local skin anesthetic before painful procedures.

When pharmacologic pain management is required, there are several nonopioid pain medication options, such as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, subdissociative doses of ketamine, nerve blockage, muscle relaxers, and gamma-aminobutyric acid agonists.

NSAIDs are the most widely used analgesic for children. A study published in 2016 found that NSAIDs were as effective as opioids in treating musculoskeletal pain; NSAIDs have also been associated with fewer adverse side effects than opioids.

For children with chronic pain (15%-35%), the review authors recommended early administration of nonopioid pain medications. For certain conditions, such as sickle cell disease, adjunct with opioids may be needed.

Clinicians should be cognizant of potential biases and disparities. Studies have indicated that minority groups and patients from lower socioeconomic status receive less opioid pain management. However, authors cautioned the increased use of opioids in these populations.

The review authors concluded, “Although the consideration of nonpharmacological and nonopioid pain management options should be used if feasible, clinicians should be careful to consider the underlying reason for the ED presentation. A patient with a traumatic injury is likely to be in pain and careful evaluation of vital signs, crying, or facial grimace can be helpful to direct escalation of pain management with careful reassessment to evaluate appropriate pain management versus evolving medical or surgical process. Appropriate recognition of pediatric pain and escalation of pain management, including opioids, should be used when appropriate.”

Reference

Chumpitazi CE, Chang C, Atanelov Z, et al. Managing acute pain in children presenting to the emergency department without opioids. J Am Coll Emerg Physicians Open. 2022;3(2):e12664. doi:10.1002/emp2.12664